The specific objective of this prospective ethnographic study is to describe and conceptualize the processes by which rural Malawian pregnant women and their partners make decisions to use skilled birth attendants for childbirth, and to explore the structural and social context in which these decisions are made and then acted upon during labor. Malawi, a South Eastern African country, has one of the highest rates of maternal deaths in the world. The World Health Organization promotes the attendance of professionally skilled providers during pregnancy and childbirth for all women as a critical component of ensuring safe motherhood and reducing the maternal mortality ratio. However, there are significant and persistent gaps in achieving skilled birth attendants for all women. Many women in Malawi still deliver without a skilled birth attendant, and little is known about how, when and by whom the decision to use a skilled birth attendant is made. Moreover, current research fails to explain why some women use skilled birth attendants for childbirth, while others do not. We propose to overcome this knowledge gap by examining the social meanings of pregnancy and birth for women and their partners, the factors that inform their decisions to use skilled birth attendants for childbirth, the extent to which the male partner is involved in these decisions, and the factors that affect the degree to which plans for the birth are achieved. The ethnographic fieldwork will involve participant observation and individual interviews with 30 women and their partners at two points in time-first in the third trimester of pregnancy to examine couples' childbirth plans, and again soon after birth to examine their actual experiences. The sample will be recruited from a health clinic and two surrounding communities, one near the clinic and one 15 kilometers away, with the assistance of a local community worker who will help identify both women attending antenatal care regularly and those who are not because the latter group is less likely to intend to plan to use a skilled birth attendant. This sampling strategy incorporates the known barriers of distance to the health center and lack of regular antenatal care. Analysis will use within and cross case analyses to identify key themes and contextual factors associated with these themes. This prospective design will enable us to examine decision-making without the potential for revisionism bias based on childbirth experience. The long- term goal of the proposed research is to provide empirical evidence to promote equitable access to and use of skilled birth attendants for Malawian women. The specific aims of this study are to (1) describe intentions to use skilled birth attendants for childbirth from the perspective of pregnant women and their male partners, and explore the structural and social context in which these decisions are made; and (2) examine the relationships between intentions to use skilled birth attendants for childbirth and actual birth experiences from the perspectives of both women and their partners.